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http://dx.doi.org/10.2147/CCID.S146258
Cryolipolysis: patient selection and special considerations
Patricia Froes Meyer1
Julio Davi Costa e Silva2
Liliane Santos de vasconcellos3
eneida de Morais Carreiro4
Rodrigo Marcel valentim da Silva5,6
1Department of Physiotherapy, Potiguar University, Natal, Brazil; 2Department of Physiotherapy, Potiguar University – UnP, Natal, Brazil; 3Department of Physical Therapy, Potiguar University – UnP, Natal, Rio Grande do Norte, Brazil; 4Center University of Rio Grande do Norte, Physiotherapy Department, Natal, Brazil; 5estácio de Sá University, Physiotherapy Department, Natal, Brazil; 6Mauricio de Nassau College, Physiotherapy Department, Natal, Brazil
Abstract: Cryolipolysis is considered a safe and effective procedure, with high patient sat-
isfaction rates, especially when compared to other procedures for localized adiposity, such
as high-intensity focused ultrasound and shock waves. Although this statement is present in
the literature, the importance of the selection of suitable patients for this type of treatment is
not well known. The objective of this study was to discuss the criteria to be considered in the
selection of patients who are candidates for cryolipolysis and assess their profile regarding their
anthropometric data, age, skin characteristics, cutaneous sensitivity, and risk pathologies for
this type of treatment. Assessing the amount of localized adiposity requires safe and validated
methods that are significant in measuring results. The aim is to achieve success in the process
of reducing adiposity guaranteeing patient satisfaction and assurance of results.
Keywords: adiposity, dermatologic physical therapy, cryolipolysis
IntroductionDifferent clinical observations have shown that the adipose tissue is sensitive to cool-
ing, promoting the development of inflammation responses, apoptosis, and consequent
reduction of localized adiposity. The premise that the adipose tissue is the cellular
formation most susceptible to cooling when compared to other cells has promoted
interest in the study of different cooling techniques to reduce localized adiposity.1
It is suggested that in cryolipolysis, the localized cooling triggers apoptosis of
adipocytes, which causes an inflammatory response and promotes slow cell mac-
rophagy.1 To this end, the applicator is placed on the area to be treated in order to
gradually extract heat until the target temperature is reached (eg, –10°C to –1°C) for
a predetermined period.2
After a single intervention, the apoptosis of the adipocytes generates a collagen
increase in the adipose tissue related to the process of lobular panniculitis and thick-
ening of the interlobular fibrous septa that occur over several months, resulting in fat
layer thickening reduction.2
The assisted cooling system selectively acts on the adipocytes, generating inflam-
mation, which results in the death of the adipose cell.3 The lipid that was previously
contained by the adipocytes will be metabolized and eliminated by the body within
around 4 months, and it will be possible to see 20%–26% fat layer reduction of the
treated area. However, 1 month after the application, clinical results may already be seen.4
It is understood that the function of a cryolipolysis apparatus is to reduce the
amount of localized adipose tissue through apoptosis induction, that is, fat cells death,
Correspondence: Patricia Froes MeyerUniversidade Potiguar, Cep: 59020160, Maxaranguape St, 550/2603, Tirol, Natal, Rio Grande do Norte 59020160, BrazilTel +55 84 9982 6469email patrí[email protected]
Journal name: Clinical, Cosmetic and Investigational DermatologyArticle Designation: ReviewYear: 2018Volume: 11Running head verso: Meyer et alRunning head recto: Cryolipolysis: patient selection and special considerationsDOI: http://dx.doi.org/10.2147/CCID.S146258
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Meyer et al
using a selective and controlled cooling system. Some cryo-
lipolysis devices differ in temperature generation, handling,
and application technique. The applicators are connected to
the skin and, through the suction mechanism, they cool the
dermis and hypodermis tissue using the cooling system of
the Peltier cells, located inside the applicator.5,6
Cryolipolysis is considered a safe and effective proce-
dure, with high patient satisfaction rates, especially where
compared to other procedures for localized adiposity, such
as high-intensity focused ultrasound and shock waves.7,8
Although this statement is given in the literature, the
importance of selection of patients suitable for this type of
treatment is not well known. Cryolipolysis is not an indica-
tion for the treatment of obese individuals, but is specific to
those who have discrete localized fat that persists despite
diets and physical activities.9,10 Therefore, relevant criteria
should be considered before cryolipolysis treatment, such
as patients’ anthropometric data, age, skin characteristics,
normal sensitivity, and risk pathologies. Assessing the amount
of localized adiposity requires safe and validated methods
that are important for result measurement.
Cryolipolysis candidate patient profileIn the study by Meyer et al,10 at the end of the data collection
of a group of patients subjected to abdominal cryolipolysis, it
was noticed that, despite weight variations, the mean deviation
was not statistically significant, which corroborates with the
previous statement that cryolipolysis is not an indication for
obese patients, but rather for localized adiposity of patients
who have little or no change in body weight. This results was
also in agreement with that of Ferraro et al,9 who stated that
the results of cryolipolysis are more visible in patients with
discrete localized fat and that it is not very effective in obese
patients. Therefore, this is a critical point to be considered in
the evaluation and selection of treatment candidates.9
It is also suggested that there is a less efficient response
in patients who had greater amount of adipose tissue, which
may be explained by the inadequate temperature or by the
difficulty that the applicator cup found in drawing a minimum
amount of tissue for the treatment, both due to the amount
of fat. Another cause of difficulty of use of the applicator
cup is the presence of fibrosis, that cause resistance of the
skin in the zone where it performs the suction. Stevens and
Bachelor11 observed that areas with fibrous fat, such as the
thigh region, present a challenge, as this type of fat is not
easily drawn by vacuum suction.
Age: when is the patient able to undergo cryolipolysis?There is no age limitation for cryolipolysis mentioned in
literature. Currently, the presence of localized adiposity
in children and adolescents, the result of poor diets and
sedentary lifestyle, is noticed every day. The candidate for
treatment should be in good health, have no history of neu-
rological or orthopedic problems, and should present normal
renal function. One study recommended the individuals to
be aged between 13 and 16 years old, to analyze the effect of
cryolipolysis in comparison to laser lipolysis in adolescents.12
Despite the age, there was good adherence to the treatment
with satisfactory results, even with a small analyzed sample.
Skin characteristics and skin sensitivityAccording to the study of Mostafa and Elshafey,12 cryolipoly-
sis is considered a safe procedure and may be applied to all
skin types without any risk, even with recurrent applications.
Klein et al13 observed skin tightness as a result of cryoli-
polysis treatment in patients with flaccidity, and even patients
who had a significant reduction in fat volume did not present
skin flaccidity. Instead, after 4 months of treatment, the firm
skin adhered well to its new bodily contours.11 Many authors
state that the mechanism by which cryolipolysis induces
skin tightness is not well understood but may be the result
of stimulated collagen production, new elastin formation,
fibrosis, or tissue compaction. It is assumed that the presence
of fibrosis observed in these studies occurs for an improve-
ment in skin flaccidity.3,13
In their study, Bernstein and Bloom et al14 observed
through ultrasound images that there was a reduction in the
fat layer after a single application. In previous studies of
abdominal adiposity cryolipolysis, the presence of fibrosis
in the adipose tissue before and 7, 15, and 45 days after the
treatment was observed through the ultrasound images.10,15
Figure 1 shows the ultrasound images of one of the
patients at 3 time points: before and 30 and 60 days after
the treatment. It is possible to see the physiological reactions
induced by cryolipolysis, such as the inflammatory process,
which appears as a whitish area, and fibrosis, caused by
adipocyte septa thickening.10
It was also possible to observe the destruction of adi-
pocyte membranes and the presence of fibrosis upon histo-
logical analysis. In a study by Zelickson et al,3 which was
carried out with pigs to study fat layer reduction of layer
adipose through cryolipolysis, the loss of adipocytes and
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Cryolipolysis: patient selection and special considerations
local thickening of fibrous septae were verified through of
histological analysis.In the study by Meyer et al,15 the application of cryoli-
polysis was performed in the abdominal region in a volunteer. This patient then underwent abdominoplasty surgery and the removed tissue was histologically analyzed. Cryolipolysis was done 45 days before surgery.15
Regarding the histological record, normal appearance of adipose tissue and adjacent tissues of the untreated region were observed (Figure 2A). It was possible to observe the destruction of adipocyte membranes and the presence of fibrosis in adipose tissue in detail (Figure 2B).
Regarding cutaneous sensitivity, it is important to con-sider that the sensorial integrity of the area to be treated is a patient exclusion criterion if not present, as due to the cold temperature induction, sensitivity control is fundamental. Dierickx et al7 reported that changes in local sensitivity may occur after cryolipolysis, with usual hyposensitivity, but the problem does not persist 3 months after application. According to Coleman et al,16 there was a transient reduc-tion of sensory function in a proportion of the individuals (neurological evaluation), which was restored in <4 weeks. There was no change in nerve fibers structure and no skin damage.16
Localized adiposity assessing methodsAssessing localized adiposity is a necessary process; how-
ever, it may not be as pleasant. Evaluating fat is, most of
the time, uncomfortable and embarrassing for the patient.17
The Localized Adiposity Physiotherapeutic Evaluation
Protocol created by Meyer et al, is a simple, low-cost, and
easy-to-use method that assists in the evaluation and thera-
peutic planning of the patient with localized adiposity who
seeks treatment. This protocol consists of identification,
anamnesis, physical examination, measurements, and tests.
Ideally, an evaluation should be performed before treatment,
with follow-up with reassessments in the middle and at the
end of treatment. Basic anamnesis information should be
collected, such as main complaint, situational background,
eating and social habits (smoking and alcoholism), use of
medication, sleep quality, and physical exercise. During the
physical examination, the following things are observed:
body shape and presence of associated aesthetic dysfunc-
tions (stretch marks, cellulite, tissue flaccidity, skin trophism,
muscular strength, and painful sensitivity). In addition, body
measurements are also carried out with the use of an adipom-
eter, a dermographic pencil, and tape measure (perimetry).17
Figure 1 Ultrasonography of one of the participants, the first taken before cryolipolysis (A) and the following taken 30 (B) and 60 days (C) later.
Long parede ABD
Parede ABD L
Long
A B
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Meyer et al
Specific tests are also performed within The Localized
Adiposity Physiotherapeutic Evaluation Protocol protocol,
such as the Hip Test and the Abdomen Test, which serve to
differentiate localized fat from flaccid skin through gluteal
contraction and abdominal contraction, respectively.17–19
Other forms of measurement of adipose tissue require
more complex investigations, such as ultrasonography and
MRI. The photos should serve as an additional analysis
resource, and care must be taken when taking the photograph
before and after the procedure to ensure standardization
of photos in relation to distance, positioning, brightness,
etc.10,12,14–16,19,20
Risk pathologies for cryolipolysisCryolipolysis is contraindicated in people with cold-sensitive
conditions such as Raynaud’s Syndrome or any disease based
on cryoglobulinemia, cold urticaria, severe varicose veins
dermatitis, or loss of skin continuity due to prolonged expo-
sure to the localized cold inducer. The literature also cites
some other conditions where there is a positive rheumatoid
Figure 2 Longitudinal microphotography, H&e 100× (A) region with areas of adipose tissue destruction; (B) region with formation of fibrous tissue.Abbreviation: H&e, hematoxylin and eosin.
A
B
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Cryolipolysis: patient selection and special considerations
factor (Sjögren’s Syndrome, lupus, vasculitis, rheumatoid
arthritis, hepatitis C).
The use of cryolipolysis used to be discouraged in patients
with cardiovascular disorders, increased cholesterol and liver
enzymes, and those with any type of hepatic steatosis-related
disease. However, many studies have clarified that there is no
change in cholesterol levels, triglycerides, and liver enzymes
that point to the risk of steatosis or worsening of such condi-
tion; therefore, these do not need to be considered as patient
exclusion criteria.
Final considerationsIt is known that although cryolipolysis is now considered a
safe and highly effective procedure, the care that must be
taken in the selection and preparation of the candidate patient
for this treatment are essential for the success of the process
and to ensure patient satisfaction and treatment results.
DisclosureThe authors report no conflicts of interest in this work.
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3. Zelickson BD, Burns AJ, Kilmer SL. Cryolipolysis for safe and effective inner thigh fat reduction. Lasers Surg Med. 2015;47(2):120–127.
4. Kilmer SL, Burns AJ, Zelickson BD. Safety and efficacy of cryoli-polysis for non-invasive reduction of submental fat. Lasers Surg Med. 2016;48(1):3–13.
5. Stevens WG. Does cryolipolysis lead to skin tightening? A first report of cryodermadstringo. Aesthet Surg J. 2014;34(6):NP32–NP34.
6. Avram MM, Harry RS. Cryolipolysis for subcutaneous fat layer reduc-tion. Lasers Surg Med. 2009;41(10):703–708.
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13. Klein KB, Bachelor EP, Becker EV, Bowes LE. Multiple same day cryolipolysis treatments for the reduction of subcutaneous fat are safe and do not affect serum lipid levels or liver function tests. Lasers Surg Med. 2017;49(7):640–644.
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